Introduction: Transcatheter aortic valve replacement (TAVR) is a well-established procedure for the treatment of severe aortic stenosis (AS) (1). Durability of those valves is still an issue concerning structural degeneration with obstruction or severe regurgitation (AR). Based on the limited literature, TAVR-in-TAVR seems to be a valid option in such cases (2).
Case report: 80-year-old female who previously underwent implantation of a bioprosthetic valve (Labcor 23) in 2014 for severe AS presented to our Department in 2021 for evaluation of severe paravalvular and intravalvular AR and secondary valvular cardiomyopathy with reduced left ventricular ejection fraction (LVEF). At first, she was planned for re-do surgery but was declined by the Heart team due to high periprocedural risk. As an alternative, she was treated with valve-in-valve TAVR, followed by a cardiac resynchronization device implantation in November 2021. During follow-up, she had frequent spells of fast atrial fibrillation accompanied by acute heart failure episodes and was eventually treated with atrioventricular node ablation in May 2023. In July 2024, combined transthoracic and transesophageal echocardiography revealed severe intravalvular AR (Figure 1), presumably due to damaged struts, with significant paravalvular leak (Figure 2), confirmed by a cardiac computed tomography scan. Based on the anatomical features, the Heart Valve Team concluded that the patient was suitable for the implantation of additional prosthesis in the form of the TAVR-in-TAVR technique. The procedure was successfully performed in October of 2024, with the implantation of the Edwards Sapien S3 valve (size 23). The new valve was positioned deeper in the left ventricular outflow tract, without impeding the anterior mitral cusp motion, and without coronary ostia obstruction (Figure 3). Postprocedural imaging revealed a significant reduction of AR, now only moderate in severity, with improved LVEF and without significant obstruction of forward flow (mean pressure gradient (PG) of 16 mmHg, and peak PG of 33 mmHg). Based on the last ambulatory visit, the patient is doing well.
Conclusion: Transcatheter treatment for the failing TAVR seems to be a reasonable option for properly selected patients. Proper preprocedural planning with multimodality imaging is paramount to prevent specific periprocedural complications, such as acute coronary obstruction (3).